epilepsy surgery: a pediatric neurologist’s perspective...epilepsy surgery: a pediatric...
TRANSCRIPT
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Epilepsy Surgery:A Pediatric Neurologist’s Perspective
Juliann M. Paolicchi, MD, MAAssociate Professor of Neurology and Pediatrics
Director, Pediatric NeurologyDirector, Pediatric Epilepsy and EEG
Vanderbilt University
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Where does it all start?
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Where does it all start?
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Where does it all start?
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Why do we ask SO MANY questions?
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Why do we ask SO MANY questions?
• The answers to the questions inform us:
– How did the epilepsy start?
– Is it genetic or related to a lesion?
– Is the epilepsy “medically intractable?”
– Is there a medical or dietary option that would be more effective?
– Where in the brain do the seizures come from?
– How do the seizures impact this person’s lifestyle: their talents and goals?
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How did the epilepsy start?
• Trauma
• Injury
• Infection
• A prolonged epilepsy
• Difficulties at birth
• No clear reason “idiopathic”
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Is it genetic or related to a lesion?
• Childhood absence epilepsy
• Juvenile Absence epilepsy
• Benign Rolandic Epilepsy
• Juvenile Myoclonic Epilepsy
• Doose syndrome
• Dravet Syndrome
• Otahara Syndrome
• Angelman’s syndrome
• Cornelia De Lange syndrome
• Aicardi’s syndrome
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Is the epilepsy “medically intractable?”
• Failure of 3 appropriate anti-epileptic medications
– Failure
– Three medications
– Appropriate
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Where in the brain do the seizures come from?
• Frontal Parietal
• Temporal Occipital
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The Presurgical Evaluation
• Detailed history and physical by a pediatric epileptologist
• Routine EEG
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Routine EEG
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The Presurgical Evaluation
• Detailed history and physical by a pediatric epileptologist
• Routine EEG
• MRI
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The Presurgical Evaluation
• Detailed history and physical by a pediatric epileptologist
• Routine EEG
• Head MRI
• Admission to the Pediatric EMU “PEMU” for identification of the seizure focus
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The Presurgical Evaluation
• Detailed history and physical by a pediatric epileptologist
• Routine EEG
• Head MRI
• Admission to the Pediatric EMU “PEMU” for identification of the seizure focus
• PET: neuroanatomic localization of seizure focus
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The Presurgical Evaluation
• Detailed history and physical by a pediatric epileptologist
• Routine EEG
• Head MRI
• Admission to the Pediatric EMU “PEMU” for identification of the seizure focus
• PET: neuroanatomic localization of seizure focus
• Neuropsychological/developmental evaluation
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The Presurgical Evaluation
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The Presurgical Evaluation
• Detailed history and physical by a pediatric epileptologist
• Routine EEG
• Head MRI
• Admission to the Pediatric EMU “PEMU” for identification of the seizure focus
• PET: neuroanatomic localization of seizure focus
• Neuropsychological/developmental evaluation
• Language localization
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The Presurgical Evalutation
• The most important aspect, and the most unique to Vanderbilt
• The Epilepsy Surgery Case Conference
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The Presurgical Evalutation
• Additional testing may be recommended:
• Additional EMU monitoring
• Interictal and ictal SPECT test
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The Surgical Evaluation
• History and physical by a trained, pediatric neurosurgeon, specializing in epilepsy surgery
• Decision by conference:
– 1 stage vs. 2 stage surgery
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The Surgical Evaluation
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The Surgical Evaluation
• Special circumstances:
– Infantile spasms
– Hemimegalencephaly
– Rasmussen’s encephalopathy
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Outcome: Epilepsy
• In a large study of children undergoing surgery over a 10 year period:
• Overall: 78% good outcome (SF or >90% reduction), 60% SF (seizure-free)
• Lesional cases vs Non-lesional cases : – 80% good outcome, 65% SF– 74% good outcome, 51% SF (no statistical difference)
• Site of seizures: – Temporal 80% good, 70% SF, – Non-temporal 78% good outcome, 61% SF (no statistical difference)
• Most significant feature:– Completeness of the resection: 92% good outcome, 76% SF
(p<0.0001)– Paolicchi et al, Neurology 2000; 54 (3): 642-647
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Outcome: Development
• Factors that improve developmental outcome:
– Younger age at the time of surgery
– Short duration of epilepsy
– Seizure freedom/outcome
– Improved developmental, dependent on the study is estimated at 59-70%
» Paolicchi, Nature Clinical Practice Neurology, 2007; 3, 662-663.
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What if my child doesn’t qualify?
• New medications
• Dietary therapy
• Vagus Nerve Stimulator Implantation
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Epilepsy Surgery:A Pediatric Neurologist’s Perspective
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